Phase 1 Pocket Card complete in 14 hospitals. 20,000+ data points gathered and analyzed. The ISRN plans to expand this study due to its clinical relevance and will likely engage additional hospital partners in the near future. Site PIs are currently engaged in designing STAR-3 interventions to test.

Wave 1 of this study is closed for enrolled. Site PIs were named across 10 hospitals. Protocol has been IRB approved. Data collection is currently underway. Wave 2 of this study is currently recruiting study sites.

Improvement Studies

Because improvement science is new, research studies are unfamiliar to most of us. The “phenomena of interest” that are the target of improvement research studies are unlike traditional research in healthcare. Until recently, health research was focused on topics such as the effect of sheering forces on pressure ulcer formation, the side effects of experimental drugs, or the effectiveness of smoking cessation programs.

With the new focus on improvement strategies, different phenomena of interest are emphasized. These include creating a culture of patient safety in an organization, engaging frontline staff in improvement, and effective ways to employ evidence-based practice across an institution.

Improvement Science Research Network (ISRN) Studies

This study will determine the types and frequency of first order operational failures that nurses self-detect during their work shifts, and will evaluate whether the self-detected failures correlate with failures that are observed by others. Nurses on participating units will use specially-designed (index sized) pocket cards to record -- in real time -- the small operational failures that they encounter. Data will be analyzed to determine a rate of small failures per patient per day.

This project will identify the impact of interruptions and distractions on medication administration errors, and will design interventions to assist in diminishing the impact of interruptions and distractions while administering medications. This multisite, two-phase study will begin with a descriptive-correlational phase in which researchers will identify and describe the various types of interruptions and distractions that occur during the medication administration process; the second phase of the study will test interventions to reduce the impact of these interruptions and distractions.

TeamSTEPPS is an evidence-based system aimed at improving patient outcomes via fostering improvements in teamwork and communication skills among members of the health care team. The goal of this study is to understand TeamSTEPPS as an improvement science demonstration model by evaluating how teams work in real-world clinical settings and identifying “gaps” in knowledge and practice with regard to optimal teamwork.